Compendium: Learning and improvement without incidents

Here’s a mini-compendium of…well, probably a lot of stuff with only a tenuous link to ‘learning’.

I tried to focus on learning that doesn’t require incidents, but you’ll find those here, too.

There’s >100 articles, mostly full-text. I think I went overboard. Unfortunately, it’s barely sorted.

It includes:

Learning from success and failure
Learning models
A little Safety-II stuff (but not much – check out my New View compendiums)
Some investigation models (not many – these will probably be covered in the future)
Learning Teams, Pre-Mortems, Shadow Box and Quality Circles
GEMBA and leader walkarounds
Kaizen, Agile and 5S approaches
A little Deming (not enough but hard to find full-text articles)
Experiential learning, scenario-based training/simulation, Psychological Safety (and its role in learning), multiple narratives, storytelling
Some work domain analysis, cognitive work analysis and hierarchical task analysis stuff
Fast & Frugal Heuristics
STAMP & STPA
WAI / WAD and procedural system learning
And more

This image has an empty alt attribute; its file name is buy-me-a-coffee-3.png

Shout me a coffee

Learning Strengths & Barriers

https://safety177496371.wordpress.com/2024/03/08/worker-centered-investigation-of-issues-with-procedural-systems-findings-from-interviews-with-a-representative-sample-of-workers-in-high-risk-process-industries/

https://safety177496371.wordpress.com/2022/06/17/can-s-ii-principles-enhance-learning-from-investigations/

https://safety177496371.wordpress.com/2024/08/07/modifying-an-accident-process-and-its-justice-system-from-single-narratives-and-retribution-to-multiple-stories-and-restoration/

https://safety177496371.wordpress.com/2024/06/26/the-learning-review-adding-to-the-accident-investigation-toolbox/

https://safety177496371.wordpress.com/2024/03/26/better-ways-to-learn-from-investigations-via-systems-thinking-leveson-and-cast-stamp-stpa/

https://safety177496371.wordpress.com/2024/02/22/shift-from-human-focused-investigations-to-system-focused-learning-and-sensemaking-in-us-forestry/

https://safety177496371.wordpress.com/2025/02/05/human-performance-tools-engaging-workers-as-the-best-defense-against-errors-error-precursors/

https://safety177496371.wordpress.com/2025/01/27/learning-from-normal-work-how-to-proactively-reduce-risk-when-nothing-goes-wrong/

https://safety177496371.wordpress.com/2024/10/23/when-things-go-right-safety-ii-in-an-academic-emergency-department/

https://journals.sagepub.com/doi/pdf/10.1177/0141076814555939

https://safety177496371.wordpress.com/2024/07/26/are-you-a-safety-bully-recognizing-management-methods-that-can-do-more-harm-than-good/

https://safety177496371.wordpress.com/2023/08/23/organizational-practices-for-learning-with-work-accidents-throughout-their-information-cycle/

https://safety177496371.wordpress.com/2022/07/21/are-we-using-the-right-tools-to-manage-variation-errors-and-omissions/

https://safety177496371.wordpress.com/2022/07/19/beyond-metrics-utilizing-soft-intelligence-for-healthcare-quality-and-safety/

https://safety177496371.wordpress.com/2022/05/31/beyond-the-corrective-action-hierarchy-a-systems-approach-to-organizational-change/

https://www.sciencedirect.com/science/article/pii/S0925753523000140

https://core.ac.uk/download/pdf/143896082.pdf

https://doi.org/10.1016/j.apergo.2023.104165

https://www.humanfactors.lth.se/fileadmin/lusa/Sidney_Dekker/articles/2009/_Huber_al_2009__Learning_from_organizational_incidents_-______resilience_engineering_for_high-risk_process_environments.pdf

https://www.standards.doe.gov/standards-documents/1000/1028-BHdbk-2009-v1/@@images/file

https://www.researchgate.net/publication/362133870_A_Framework_to_Strengthen_Learning_Culture_and_Safeguards

https://lup.lub.lu.se/student-papers/search/publication/8924233

https://www.researchgate.net/publication/340141827_Evaluation_of_Learning_Teams_Versus_Root_Cause_Analysis_for_Incident_Investigation_in_a_Large_United_Kingdom_National_Health_Service_Hospital

https://www.researchgate.net/publication/363112329_Experience_of_learning_from_everyday_work_in_daily_safety_huddles-a_multi-method_study

https://link.springer.com/article/10.1186/s41077-021-00163-3

https://www.researchgate.net/publication/220534678_Implementing_New_Practices_An_Empirical_Study_of_Organizational_Learning_in_Hospital_Intensive_Care_Units

https://publications.ergonomics.org.uk/uploads/Understanding-how-work-as-done-of-incident-investigators-supports-a-safety-II-approach.pdf

https://lup.lub.lu.se/student-papers/search/publication/9153670

https://lup.lub.lu.se/student-papers/search/publication/8994089

https://dspace.lib.ntua.gr/xmlui/bitstream/handle/123456789/53843/1-s2.0-S0925753520300291-main.pdf?sequence=1

https://journals.sagepub.com/doi/full/10.1177/00236772211037177

https://safety177496371.wordpress.com/2025/02/08/learning-to-fail-intelligently-amy-edmondson/

https://safety177496371.wordpress.com/2024/07/03/reﬂections-voice-and-silence-in-workplace-conversations/

https://pmc.ncbi.nlm.nih.gov/articles/PMC9684018/

https://safety177496371.wordpress.com/2024/06/10/fix-and-forget-or-fix-and-report-a-qualitative-study-of-tensions-at-the-front-line-of-incident-reporting/

https://safety177496371.wordpress.com/2022/12/06/when-problem-solving-prevents-organizational-learning/

https://static1.squarespace.com/static/53761774e4b0e8c9b2acd2a4/t/629fcc85185ef04c9d2549bc/1654639749195/Strategies+for+Learning+from+Failure.pdf

https://safety177496371.wordpress.com/2023/08/11/using-participatory-video-to-understand-subcontracted-construction-workers-safety-rule-violations/

https://www.researchgate.net/profile/Jody-Gittell/publication/229509485_High-quality_relationships_psychological_safety_and_learning_from_failures_in_work_organizations/links/6442867264d7bb5ae10f29a2/High-quality-relationships-psychological-safety-and-learning-from-failures-in-work-organizations.pdf?trk=public_post_comment-text

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=f3ec2a4c342d125bd06c0b706b6a5e22b82056c2

https://safety177496371.wordpress.com/2022/11/17/implementing-new-practices-an-empirical-study-of-organizational-learning-in-hospital-intensive-care-units/

https://www.academia.edu/download/36604260/ORGANIZATION_CULTURE_Organization_at_the_limit.pdf#page=81

https://coller.tau.ac.il/sites/nihul.tau.ac.il/files/media_server/Recanati/management/hurvitz/forms/articles/more_articles/Linking_leader_inclusiveness_to_work_unit%20_performance%20_The_importance_of.pdf

https://safety177496371.wordpress.com/2022/10/18/learning-from-mistakes-is-easier-said-than-done-group-and-organizational-influences-on-the-detection-and-correction-of-human-error/

https://safety177496371.wordpress.com/2022/05/16/incident-learning-system-offers-a-non-interpersonal-platform-to-speak-up/

https://www.mdpi.com/2071-1050/12/12/5164/pdf

https://fis.uni-bamberg.de/server/api/core/bitstreams/84e5e2e2-f92b-4b2a-8c9c-b3a70d11398f/content

https://wrap.warwick.ac.uk/id/eprint/81222/1/WRAP_1471484-ny-240816-sujan_huang_braithwaite_safety_science_2016_for_web.pdf

https://www.academia.edu/download/50540972/GHERARDI.PDF

https://www.nature.com/articles/npp2013191.pdf

https://www.researchgate.net/profile/David-Holman-6/publication/228052384_A_Walk_on_the_Safe_Side_The_Implications_of_Learning_Theory_for_Developing_Effective_Safety_and_Health_Training/links/5fdb25c4a6fdccdcb8d1d2fa/A-Walk-on-the-Safe-Side-The-Implications-of-Learning-Theory-for-Developing-Effective-Safety-and-Health-Training.pdf

https://www.hbs.edu/ris/Publication%20Files/02-062_0b5726a8-443d-4629-9e75-736679b870fc.pdf

https://www.apa.org/pubs/journals/releases/apl-96-1-46.pdf

https://eprints.teachingandlearning.ie/id/eprint/3755/1/Stuart%202014.pdf

https://drive.google.com/file/d/1F2Uz8eyDdgHE2KA-jzdMukLmPzLdY5PO/view

https://research.qut.edu.au/centre-for-future-enterprise/wp-content/uploads/sites/285/2023/01/1-s2.0-S0925753520302216-main.pdf

https://eprints.qut.edu.au/211004/1/86098633.pdf

https://www.sciencedirect.com/science/article/pii/S0925753514000976

https://www.academia.edu/download/47466727/00b4952313cee7f9a6000000.pdf

https://open-publishing.org/journals/index.php/jutlp/article/view/678/678

https://www.tandfonline.com/doi/pdf/10.2147/JHL.S70115

https://doi.org/10.1016/j.socscimed.2021.114375

https://bmjleader.bmj.com/content/5/2/121

https://www.academia.edu/download/89241649/301341279.pdf

https://link.springer.com/content/pdf/10.1186/s13012-022-01226-3.pdf

https://digitalcommons.unl.edu/cgi/viewcontent.cgi?article=1006&context=jfspresearch

https://www.researchgate.net/profile/Olaf-Timmermans/publication/230651758_Team_learning_and_innovation_in_nursing_teams_Results_of_a_comprehensive_research_project/links/0fcfd50295ae4ad9d2000000/Team-learning-and-innovation-in-nursing-teams-Results-of-a-comprehensive-research-project.pdf

https://researchoutput.csu.edu.au/ws/portalfiles/portal/413623818/394566649_published_article.pdf

https://www.researchgate.net/profile/Miriam-Manzanares/publication/271921282_The_Influence_of_Change-Oriented_Leadership_and_Psychological_Safety_on_Team_Learning_in_Healthcare_Teams/links/56966b1a08ae1c427903c564/The-Influence-of-Change-Oriented-Leadership-and-Psychological-Safety-on-Team-Learning-in-Healthcare-Teams.pdf

https://samforsk.brage.unit.no/samforsk-xmlui/bitstream/handle/11250/2456918/When+Safety+Science+Meets+the+Practitioners%20(9).pdf?sequence=4

https://link.springer.com/content/pdf/10.1186/s12912-018-0318-7.pdf

https://www.researchgate.net/profile/Meixia-Liao/publication/337196277_Quality_control_circle_a_tool_for_enhancing_perceptions_of_patient_safety_culture_among_hospital_staff_in_Chinese_hospitals/links/621af4ec2542ea3cacb45b71/Quality-control-circle-a-tool-for-enhancing-perceptions-of-patient-safety-culture-among-hospital-staff-in-Chinese-hospitals.pdf

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0202616&type=printable

https://safety177496371.wordpress.com/2023/11/01/impact-of-leadership-walkarounds-on-operational-cultural-and-clinical-outcomes-a-systematic-review/

https://safety177496371.wordpress.com/2023/08/10/systematic-review-of-safety-walkaround-evidence/

https://safety177496371.wordpress.com/2025/01/06/the-twenty-foot-rule-and-safety-leadership/

https://safety177496371.wordpress.com/2024/10/21/management-walk-arounds-lessons-from-the-gulf-of-mexico-oil-well-blowout/

https://safety177496371.wordpress.com/2022/07/05/i-think-we-should-just-listen-and-get-out-a-qualitative-exploration-of-views-and-experiences-of-patient-safety-walkrounds/

https://safety177496371.wordpress.com/2022/06/28/walkrounds-in-practice-corrupting-or-enhancing-a-quality-improvement-intervention-a-qualitative-study/

https://safety177496371.wordpress.com/2022/06/21/safety-management-by-walking-around-smbwa-a-safety-intervention-program-based-on-both-peer-and-manager-participation/

https://www.mdpi.com/2313-576X/9/4/70/pdf

https://aeasseincludes.assp.org/professionalsafety/pastissues/061/02/F2_0216.pdf

https://www.cambridge.org/core/services/aop-cambridge-core/content/view/D7A531C12ECEC668283CB9C880E443E9/S1481803520003802a.pdf/going_to_the_covid19_gemba_using_observation_and_high_reliability_strategies_to_achieve_safety_in_a_time_of_crisis.pdf

https://www.academia.edu/download/87879703/article_1708_da343f3eccfac7fd4db6f12502a71449.pdf

https://watermark.silverchair.com/e1.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAAzYwggMyBgkqhkiG9w0BBwagggMjMIIDHwIBADCCAxgGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMy5lbSlKEpYnw9uQSAgEQgIIC6WUpgpQ1AjXdjh6n2nxBaK8OX9sxe5j3XvpGWI3Nm6Y2xGov_AlnF3ceLsD-xHKlObpWjcg1FUERLrG3w4ECAwIHVHy-GQey1ywXQ3MaVgdTJO-jBDRl2gGMH5RNoAvWIODxEKeiBYhBIwOYzqJ6bfDGGr34K0De0PiPPZ_gX1SNBLJ_OTh1qyamOmt9j-_8ybOvgAx82dXyg-ROGUIJCepRJWHwyYVK5ru-IQDzN8VeMi7CfEZL0bBot9cjIAnEfDyS4tNQMRXn6WY7jEJGwnqcR5237nPjg7X3Da5M9NCxYD_jAK1mSidDdI89aLuDKPZHR18rAbxnAyLJFb–rEgfb-E2gMB87H9uMmU28gRgOfTUgnfigOYzgkKSD6PXUdkx_EK05nUNKP-Lse2dlERzdv1cv892ESRYvwUW77yj5SWN–sseYwPV0fxgeaybfdKW-9b7PB_pM-oUSbVbaUj2Md1iUIbPs47KHbvKzubSLBsIHlLzYIip-BiWJDx9YGiAp21q1poyYBgiE0yd0A8WDClbmIjpNpXGqvbuT-NV-Y93H363qcgtx_UFWPZRZWQPRCvgT8angzUDYyg_CR1wgpmByA-wobU-ySYyjJJnFkSnUsGkjzPtd6eXrDqCNmZ8vFMQihmHPQxTVCaucSjUpiaI6FuPVeP2BtRr5_wO_kVU_nmcEjYNLGnyx7pqmJje-oiuezYwpy0E6e8njFA9Zpwp8R6o5fA4_cz3fpz9X0LWuEPF_5njpPbXLYgvqW_j-GN7cMHuZDwMx_rb75T4wm8L9_4iLAGa0vl-oBR-jd8SARrL9pnVXsOGu_OtMJ_BgjW6f1zbDMbEvN34ihG364W8xi9Z2xfuJ6wfZ8FY8qcpayz6h0ryKaCQMBavugNDpBcwUKpMzg-tvju4k-ZhIC9fNIJhwXblXxfnZ0FpMZdOwcx83iWSlPHK98K5CVBbON56_b_JceoK8lBboDeH8-PBoCKy38

https://journals.sagepub.com/doi/pdf/10.3233/WOR-121576

https://leanconstruction.org.uk/wp-content/uploads/2018/09/Leino-et-al.-Improving-Safety-Performance-Through-5S-Program.pdf

https://iehouse.org/wp-content/uploads/2018/07/1-s2.0-S0925753517312389-main.pdf

https://aeasseincludes.assp.org/proceedings/2007/docs/561.pdf

https://repository.uwl.ac.uk/id/eprint/6075/1/Sikora_Atkin_and_Panagopoulos_JSS_2016_Lean_Six-Sigma_in_aviation_safety_an_implementation_guide_for_measuring_aviation_system%E2%80%99s_safety_performance.pdf

https://www.researchgate.net/profile/Selim-Ahmed/publication/365772190_Role_of_Lean_Six_Sigma_approach_for_enhancing_the_patient_safety_and_quality_improvement_in_the_hospitals/links/6384b50e7b0e356feb92bac5/Role-of-Lean-Six-Sigma-approach-for-enhancing-the-patient-safety-and-quality-improvement-in-the-hospitals.pdf

https://doi.org/10.1016/j.trpro.2017.03.005

https://journalmt.com/pdfs/mft/2022/03/10.pdf

https://doi.org/10.1016/j.pcorm.2021.100197

https://www.scirp.org/pdf/eng20120700005_99347612.pdf

https://aeasseincludes.assp.org/professionalsafety/pastissues/065/02/F2Nev_0220.pdf

https://www.unife.it/medicina/lm.infermieristica/studiare/minisiti/scienze_giuridiche_economiche/modulo-di-economia-aziendale/2017-18/caso-lean.pdf

https://doi.org/10.1016/j.ssci.2016.07.006

https://doi.org/10.1016/j.jclepro.2020.121346

https://doi.org/10.1016/j.ssci.2012.01.004

https://doi.org/10.1016/S0022-4375(02)00008-7

https://safety177496371.wordpress.com/2024/10/01/the-etto-principle-as-ettoing-or-occams-razor-redux/

https://safety177496371.wordpress.com/2022/11/14/using-safety-ii-and-resilient-healthcare-principles-to-learn-from-never-events/

https://www.academia.edu/download/98266084/s0022-4375_2802_2900008-720230205-1-p2pay9.pdf

https://link.springer.com/content/pdf/10.1186/s12913-017-2531-6.pdf

https://aeasseincludes.assp.org/professionalsafety/pastissues/050/06/040605as.pdf

https://www.researchgate.net/profile/Ali-Karakhan-2/publication/317371469_Six_Sigma_Construction_Safety_Using_the_DMAIC_Cycle_to_Improve_Incident_Investigations/links/593ace2c0f7e9b3317010cb1/Six-Sigma-Construction-Safety-Using-the-DMAIC-Cycle-to-Improve-Incident-Investigations.pdf?origin=journalDetail&_tp=eyJwYWdlIjoiam91cm5hbERldGFpbCJ9

https://aeasseincludes.assp.org/proceedings/2007/docs/561.pdf

https://qualitysafety.bmj.com/content/qhc/27/9/710.full.pdf

https://www.shadowboxtraining.com/wp-content/uploads/2021/05/The_ShadowBox_Approach_to_Cognitive_Skills_Trainin.pdf

https://www.academia.edu/download/83052929/Klein_etal_NDM11_2013_ShadowBox_Method.pdf

https://doi.org/10.1016/j.promfg.2015.07.444

https://www.researchgate.net/profile/Julie-Gore/publication/320146441_Naturalistic_Decision_Making_and_Uncertainty_Proceedings_of_the_13th_Bi-Annual_Naturalistic_Decision_Making_Conference_University_of_Bath_UK/links/59d0aeb30f7e9b4fd7f9fcbf/Naturalistic-Decision-Making-and-Uncertainty-Proceedings-of-the-13th-Bi-Annual-Naturalistic-Decision-Making-Conference-University-of-Bath-UK.pdf#page=258

https://www.researchgate.net/profile/Emily-Newsome/publication/283663237_Using_the_ShadowBox_Method_to_Detect_the_’Investigator’_and_’Proceduralist’_Mindsets_in_Frontline_Social_Workers/links/574307ac08ae9ace8418be74/Using-the-ShadowBox-Method-to-Detect-the-Investigator-and-Proceduralist-Mindsets-in-Frontline-Social-Workers.pdf

https://www.acpjournals.org/doi/full/10.7326/0003-4819-158-5-201303051-00010?journalCode=aim

https://www.academia.edu/download/80408057/9035.pdf

https://www.researchgate.net/profile/N-Dahlstrom/publication/50917189_Fidelity_and_validity_of_simulator_training/links/0fcfd509d11248e30e000000/Fidelity-and-validity-of-simulator-training.pdf?_sg%5B0%5D=started_experiment_milestone&origin=journalDetail

WAD / WAI (Work-As-Done / Work-As-Imagined)

https://safety177496371.wordpress.com/2024/03/25/the-realities-of-procedure-deviance-a-qualitative-examination-of-divergent-work-as-done-and-work-as-imagined-perspectives/

https://safety177496371.wordpress.com/2024/01/13/links-between-procedure-use-procedure-quality-worker-experience-and-task-frequency/

https://safety177496371.wordpress.com/2023/11/08/reducing-gaps-between-paper-and-practice-requires-more-than-a-technical-alignment/

https://safety177496371.wordpress.com/2023/10/23/safety-artifacts-in-oil-and-gas-industry-an-analysis-of-permit-to-work-process/

https://safety177496371.wordpress.com/2023/03/24/using-functional-resonance-analysis-method-to-understand-construction-activities-for-concrete-structures/

https://safety177496371.wordpress.com/2022/11/10/investigating-a-new-classification-to-describe-the-differences-between-work-as-imagined-and-work-as-done/

https://safety177496371.wordpress.com/2022/07/12/understanding-complex-work-using-the-resilience-mechanisms-framework-an-ethnographic-study/

https://safety177496371.wordpress.com/2022/06/17/can-s-ii-principles-enhance-learning-from-investigations/

https://safety177496371.wordpress.com/2022/01/13/where-two-ends-meet-operator-and-stakeholder-perceptions-of-procedures/

https://safety177496371.wordpress.com/2021/04/06/mind-the-gap-examining-work-as-imagined-and-work-as-done-when-dispensing-medication-in-the-community-pharmacy-setting/

https://safety177496371.wordpress.com/2024/03/17/wai-vs-wad-in-high-hazard-procedural-systems/

https://safety177496371.wordpress.com/2021/12/09/navigating-operating-procedures-in-everyday-work-in-a-petrochemical-facility-a-comparative-analysis-of-wai-and-wad/

https://www.researchgate.net/profile/Gary-Klein-3/publication/380100098_klein1989pdf/data/662ad9dd08aa54017ac15c04/klein1989.pdf

https://doi.org/10.1136/bmjqs-2022-015464

https://doi.org/10.1016/j.apergo.2024.104314

https://www.upstate.edu/academic-affairs/pdf/nothingwrong_what-do-i-debrief.pdf

https://doi.org/10.1016/j.aap.2013.05.022

https://www.dau.edu/sites/default/files/Migrated/CopDocuments/ADF%20Work%20Domain%20Analysis%20Guide.pdf

https://doi.org/10.1016/j.ssci.2022.105922

https://doi.org/10.1016/j.apergo.2005.06.003

https://research.usc.edu.au/esploro/fulltext/journalArticle/Work-domain-analysis-and-road-transport/99450009102621?repId=12126437560002621&mId=13127247670002621&institution=61USC_INST

https://research.usc.edu.au/esploro/fulltext/conferencePaper/Pathways-to-failure-Using-work-domain/99448933002621?repId=12126072350002621&mId=13126982210002621&institution=61USC_INST

https://research.usc.edu.au/esploro/fulltext/journalArticle/Designing-sociotechnical-systems-with-cognitive-work/99447769602621?repId=12125966380002621&mId=13133760240002621&institution=61USC_INST

https://backend.orbit.dtu.dk/ws/portalfiles/portal/88456750/ris_m_2871.pdf

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=8b7c60c416863120b4701b4fc21962a316f505ef

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=2aa7666b780fc14ff171673654acb721ed81c6f0

https://www.hpog.org/assets/documents/Guidance-on-human-factors-safety-critical-task-anlaysis-jk.pdf

https://www.energyinst.org/technical/publications/topics/human-and-organisational-factors/guidance-on-human-factors-in-task-based-risk-assessment (Free when you sign up)

https://doi.org/10.1016/j.ssci.2019.07.028

https://onlinelibrary.wiley.com/doi/pdf/10.1111/hex.13478

https://pmc.ncbi.nlm.nih.gov/articles/PMC8024801/pdf/jtd-13-03-2044.pdf

https://watermark.silverchair.com/ael067.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAA0kwggNFBgkqhkiG9w0BBwagggM2MIIDMgIBADCCAysGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQM3fna_W4YSBfdRaIiAgEQgIIC_CxMiLDOY7kpibqduVyDydlx0xzJS-at2bAFWcj0I4jkMBIccc3lxgy0iMVEgm3Z756S7rPYmJ2eRBJwwboWgw75Jk5AHmnqyScKJtiKyn2ABlfLFY3W5gaUD5sZCvzf3-sP-M2qPP-1SlXIFILzoGY5gt8y6tBGa6gXaNEM8PPCB-jilmItyHe3ZUzL4hiu0EEj9uUgUlAYAJNc4zYip7FfixhgXtn9JbKb0hAxudtky2YsxGQ7MdoJEHUixaAWt1QUMh4Cw-PGdx7m8zInBGTKKHzPaLZFa4awkDwyzCm-4NPtkyPkLqKlMthwDa3O3GCU13-Z6OppT9b4PSQaRaW69CeOQ6u8c8naD1kSBVSMAy7xhKfJ0Kq_OlkIQM8-57gJN1wPl1WepYajAIORUwIb_sTVYX1m9490crsTOOMoMcqvU_2tOC7icvY8o6S3py1rNOVK1bxnFy_MHK4oVSOKJQO_mfGe5L0176bLVdKvQ7UIKcEwQFgHtHTOaxJr_oige24jy-MBCiA79qlCxpX7jZu9x3hUpdIqZOuiQH7gajCQzWbyC2zvdPYU3ZcPGwthb1LNcTqmlxKcXnpgtfGfWP0ni7WfqZOZmTdvOJxR6haAsxPmM-Z-Z_FJmnlZ1IRCZEErTyJZ5Lf0IICXejyPO5pY-VHq5TCVxMQ95l0W7-K5cBk13x5jPH__6Lqc_X8KYlVSj4aL5EBVlx2YOvxEEidw7rF8P2QA9JfCt40AwTRNEGx4T8qMK6Rfef86yAqOVs4vbmFmydE3UnhUcm9gING-ltFaoH5SFAQ78IEmhsFvhmN6IIONn_1L-fU_fXN6WyG2Lb-ikEsTRlZeO2HUTDE5FgoBHhyAxWBTWT5Aa-kHUS-Zec18kVVxBzzJhsCp63bJ88Me_yqpPUYqCBUpF_sIGTu7vI-x7FbzuXgakZe-57zTCPgZE5aevkp-OfksRu4tsiffo_xTRErxF4ozYt6QO9EzcYGDDS0eAhoLRQ5X02krnQP3vaGQ

https://doi.org/10.1016/j.sempedsurg.2020.150906

https://www.tandfonline.com/doi/pdf/10.1080/10872981.2017.1272838

https://pmc.ncbi.nlm.nih.gov/articles/PMC3415625/pdf/TONURSJ-6-82.pdf

https://www.researchgate.net/profile/Michelle-Wallace/publication/45600855_Organizational_learning_and_the_learning_organization/links/0c96052b60566337c8000000/Organizational-learning-and-the-learning-organization.pdf

https://www.researchgate.net/profile/Amy_Edmondson/publication/256003694_Three_Perspectives_on_Team_Learning_Outcome_Improvement_Task_Mastery_and_Group_Process/links/00b4951fe6c3c01fd5000000/Three-Perspectives-on-Team-Learning-Outcome-Improvement-Task-Mastery-and-Group-Process.pdf?_sg%5B0%5D=started_experiment_milestone&origin=journalDetail

https://pmc.ncbi.nlm.nih.gov/articles/PMC1765808/pdf/v013p00ii3.pdf

https://www.researchgate.net/profile/Amy_Edmondson/publication/268328210_Psychological_Safety_Trust_and_Learning_in_Organizations_A_Group-level_Lens/links/5488c5460cf268d28f08fef8.pdf

http://ereserve.library.utah.edu/Annual/MGT/6050/Diekmann/speeding.pdf

https://www.iogp.org/bookstore/product/learning-from-normal-work/ (Free with sign up)

https://www.diva-portal.org/smash/get/diva2:1520960/FULLTEXT01.pdf

https://doi.org/10.1016/j.ssci.2020.104827

https://www.researchgate.net/profile/Rogier-Woltjer/publication/237088894_Patient_safety_investigation_through_the_lens_of_FRAM/links/553115710cf27acb0de9948c/Patient-safety-investigation-through-the-lens-of-FRAM.pdf

https://www.erikhollnagel.com/onewebmedia/RAG%20Outline%20V2.pdf

https://www.researchgate.net/profile/Moacyr-Cardoso-Junior/publication/353404177_PARADIGM_SHIFT_IN_SAFETY_MANAGEMENT_IN_THE_BRAZILIAN_ARMY_AVIATION_PROPOSAL_AND_VALIDATION_OF_A_RAG_QUESTIONNAIRE/links/60fab1b72bf3553b2907113f/PARADIGM-SHIFT-IN-SAFETY-MANAGEMENT-IN-THE-BRAZILIAN-ARMY-AVIATION-PROPOSAL-AND-VALIDATION-OF-A-RAG-QUESTIONNAIRE.pdf

https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0239472&type=printable

https://curate.nd.edu/articles/journal_contribution/Discovering_Analyzing_and_Managing_Safety_Stories_in_Agile_Projects/24822756/1/files/43662435.pdf

https://arxiv.org/pdf/1911.12590

https://doi.org/10.1016/j.infsof.2018.06.004

https://doi.org/10.1016/j.mtcomm.2019.100548

https://www.academia.edu/download/86728419/Anderson_et_al__1994__Deming_Management_Method.pdf

https://shudo-u.repo.nii.ac.jp/?action=repository_action_common_download&item_id=291&item_no=1&attribute_id=18&file_no=1

https://usu.instructure.com/files/61598715/download?download_frd=1&verifier=GBQ1vp1aO9RFjtA1xTNgkzYGxj6W2JbXrJokP5Ut

https://journals.sagepub.com/doi/pdf/10.3233/HSM-1991-10403

https://doi.org/10.1016/j.cppeds.2018.08.013

https://watermark.silverchair.com/i2589-9449-6-3-96.pdf?token=AQECAHi208BE49Ooan9kkhW_Ercy7Dm3ZL_9Cf3qfKAc485ysgAAA3QwggNwBgkqhkiG9w0BBwagggNhMIIDXQIBADCCA1YGCSqGSIb3DQEHATAeBglghkgBZQMEAS4wEQQMUKp_mpnsws_iPRlEAgEQgIIDJ6urvPRNAJBFm-vv4xMRzQVlcjGryI_iQIvLvSzTTfdQklg9VhIlhYUTrdN1yu1xgmCDNq0vYsB3VTx_dxy6zxiSJfq2ivxwdNyywkmhSVWiWG7xx_mEh8KAB9eLU2Bs0sKsPDhZF0Vf8d8ljj1eMPBUxr_fwaTppfGAPcxbmewyhgrwkw1DCRrI2tNWeeY7llTjhQIoeYA5htkDYomZ5lGMkOQR13FZeErbmJzUi0JQtLBN_bs_pa5nhaNYxmxHyS8IlUZfhJc48kvhYSnPfQeYaWxZra1sIy2IsIDeE6f9KqNTj3oddaiNwcrsNJCozcYdK6Q4VKYL2xAWvIOh2EwQH-bIKnS0sQy0wIsuaq86NTe8h5yf4iaP7zz0faK9oROv0NhqOmkcd8AdldlZRal0w9yQKCRw2mAKIxg_aXOKWOdn-iBQhGD10J-jFj-P2aXFugefv_ny1e2U6qpHO31o-QDQN_adrO2gduwROv6dRNept7BuYx9_5cLVppJuB_-2zUSdazTeWtG7v9WfUYN2KgsoFV6yhstuWaaV5FwLJk4dIRmzOfOnxwSj9WkJ1ySK3JQqfLMXfro7yJYAiG15tPmftODCHET_wbNGCvxxWY1CYSpmIE-PtPfnPGvW5D4VTGCIi9jx3ANNHILbCFswnSln4-nHG_DbGzDOtqoV-jS1K4ErGLfmWiNonWrabqw0vKIC0Gd-oQddX9V17OCZIOvCIPIsEePHpg688oXf24HRdzztMozSafACNemoo06ChcO3P-QW1TXNH1twjFdTkXZzrpHHW9fSR1b4O_zp7yi_DkAjRcSts4AwH3p7bDHgK2pgHNI1djlV6QlNLa2LN6ckPCs2dw3-Ib6w9is5Ew6c7Kb553J5NYJdYDbzWDdCio-wojs_Sm_FUt1lBp-D_XnNIECAckKLIrYeXQ7-znIiovuY5A4X3Fl6k11KTLoNJrZcVPX4kx_9QgcA6Oo5l3_Ko1uvj_aaBVFK8Nj2f_5hcAcLOJ-E8T-Ebl43QcO089D9tlirfqjwwoz__0Chlngi-jHJY5xjbovkkZgD8LUN4CjWrA

https://pdf.sciencedirectassets.com/280203/1-s2.0-S1877050922X00045/1-s2.0-S1877050922004963/main.pdf?X-Amz-Security-Token=IQoJb3JpZ2luX2VjEP%2F%2F%2F%2F%2F%2F%2F%2F%2F%2F%2FwEaCXVzLWVhc3QtMSJIMEYCIQDwWDZ6wY5b5imlzm0A70SwooidytEoEgp2TiE54G6ZaAIhAL%2FUFCNSHEqUEkL6IrboNh0smDkkPqUWBZ%2Fkc%2FYuhzb0KrMFCDgQBRoMMDU5MDAzNTQ2ODY1IgwZwboiSDhHUf35BMEqkAXJTrfnXqtfQT%2FdDrLDpJ4HjVm%2B55OSWB8SMFx5jK3TMX9V1LnsZb9I0Er1%2BmhRUQXWLTyesTCz3BzHLY%2Bqq11VzJKHTTv%2FED8jLi7EpN23X7a9Lw%2FNLl5iJ3TSgG3SubogegRMWZj%2BCiGegEVrjFC55ldlm0sbeoC8a2yiU0%2Btf1vXxkPm1rP3ruTdAoxPh%2Bb9Tmwos%2F%2FYe4oKuiUR7T1qms0F9TWR00XIV84uucaD5kaXJJ8NfnelZlKkTqgukX1fJm3GJw2hEiGvbJhfGQF5yf5DsjHKIwAcZGByVVaxhu8rn3Xzldtk6gR9%2BTPUuiJSAe2XrC8ssvRfyNp7GdBwFQ%2BKm4II8bXgo5lP5rH33GAHrFYcT76R79cmnC64DLhb5d27N4Bx%2FKJ5qyT2Wz27b%2FX9Z1nNDY%2BetOj0s6icUbVp3D2WUhAwl9szOeNbvUYUbU3DSPr0bX6pVBNFx8zysI%2ByWv40GSR4rUTZ%2Bbun23L0xKZGgs%2FyaDHh2Fu61fANP6bCgNC4cWXwfS5EPa3NZrjUhqnx1WpnmS%2FE00nGh0ESOCra1iYXhAT2C9Ma0ca9XLxyhl8V%2BA5Wc8imQKe2ZKtka8OVTTBlydMfuMBouOKUMk3PGYm4gOcggak5uxWBnvuVhVXRDFsN6Rabokg7Io03x7ZO4wqpl1Wx9mSvnKVFnHIMgh0Bu31%2FvKl1QkIkbFvdyBI%2B8xZkmh0dJ20SKgMYDXmLX1U31FGObTbegdwg71XBZVwW0w0YZrRSMtGH0NXN19dtC0EeIiFz%2FqQb6uBBvSgoNiyOS9dfp7j523pgVcxJo8bDM2ETR7SzyLT%2BRvMoi2%2BM4agLqzveddUDnNSiTD2bK7T5tTIKLwJ1%2BDDD8fO9BjqwAQJjHDo9J475QI5KhqvwJbIqEzO4zkqrysaCR9Nb4vSRDdhavmwqrzPjPeWIGWbWsHet4eT1p9vdYsJy%2BW3gPCUfX7%2FyIsrEAChxQt90Z2sHqLoEF%2B6LURoa8m4AAnVJDuqjzsZX6ThoHN3yCSJxQoGyoGV5cHc20jqS6laVijPJdhggyi8nIoaV0XV2Wt%2FW8pak6%2FfraZYhBhN3aus4LVCa7bME%2ByUZrubY52vcdOlT&X-Amz-Algorithm=AWS4-HMAC-SHA256&X-Amz-Date=20250224T235319Z&X-Amz-SignedHeaders=host&X-Amz-Expires=300&X-Amz-Credential=ASIAQ3PHCVTY6QM6VMD6%2F20250224%2Fus-east-1%2Fs3%2Faws4_request&X-Amz-Signature=c15940eb2a168ab3bb48144e9a02f7e1b59e24a00ba6fde692d1572fe53a46f2&hash=14cdb5f95ad4840a5ac0d03d2ce41d81b6e26af56dd69bd95bbb76efdc9eecf7&host=68042c943591013ac2b2430a89b270f6af2c76d8dfd086a07176afe7c76c2c61&pii=S1877050922004963&tid=spdf-20ae14f1-d0ac-4fa0-9a1a-b57044e65bb9&sid=5cbfad731439154a0768b2b9c89d6600efbagxrqa&type=client&tsoh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&rh=d3d3LnNjaWVuY2VkaXJlY3QuY29t&ua=04135d53585252010453&rr=91735fd4d9d7d70d&cc=au